Method and apparatus for verifying bradycardia/asystole episodes via detection of under-sensed events

ABSTRACT

A system and method for detecting and verifying bradycardia/asystole episodes includes sensing an electrogram (EGM) signal. The EGM signal is compared to a primary threshold to sense events in the EGM signal, and at least one of a bradycardia or an asystole is detected based on the comparison. In response to detecting at least one of a bradycardia or an asystole, the EGM signal is compared to a secondary threshold to sense events under-sensed by the primary threshold. The validity of the bradycardia or the asystole is determined based on the detected under-sensed events.

TECHNICAL FIELD

The present disclosure is related to medical devices, and in particularto medical devices that sense a signal indicative of cardiac activity.

BACKGROUND

A variety of medical devices exist for monitoring patient cardiacactivity. For example, these devices may be implantable, subcutaneous,or adherent and may include one or more leads for monitoring electricalsignals, e.g., intrinsic depolarizations of the hearts. Methods are usedto extrapolate from the monitored electrical signals various cardiacevents such as P-waves, R-waves and T-waves (referred to generically assensed events). Based on these sensed events, cardiacepisodes/conditions can be detected. For example, both bradycardia andasystole episodes are characterized by long pauses between sensed events(e.g., R-waves that signal a ventricular depolarization/contraction).However, a determination that a patient is experiencing a bradycardia orasystole episode is based on the assumption that all events have beenproperly sensed by the medical device. If the medical deviceunder-senses one or more events within the episode, the medical devicemay incorrectly determine that the patient is experiencing abradycardia/asystole type event.

In particular, the primary cause for inappropriate bradycardia/asystoledetection is due to frequent premature ventricular contractions (PVCs)characterized by a wide QRS complex, PVCs characterized by a very largeQRS amplitude, and small/wide QRS complexes. In the case of PVCscharacterized by a wide QRS complex, the low-frequency characteristic ofthe QRS complex results in the PVC being under-sensed. In the case ofPVCs characterized by a very large QRS amplitude, the amplitude of thePVC beat results in the under-sensing of normal QRS amplitudes thatfollowing the PVC beat. In both cases, the result of under-sensingevents results in an inappropriate detection of a bradycardia/asystoleevent.

It would therefore be desirable to minimize the inappropriate detectionof bradycardia/asystole episodes.

BRIEF SUMMARY OF THE INVENTION

According to an exemplary embodiment, a method includes sensing anelectrogram (EGM) signal and comparing an amplitude of the EGM signal toa primary threshold to sense events in the EGM signal. The presence ofat least one of a bradycardia or an asystole is detected based on thesensed events, and in response to detecting at least one of abradycardia or an asystole, the EGM signal is compared to a secondarythreshold to sense events under-sensed by the primary threshold. Basedon the detection of under-sensed events, a determination is made whetherthe bradycardia or the asystole is false.

According to an exemplary embodiment, a medical device comprises asensing unit, a primary sensing channel, a secondary sensing channel andprocessor. The sensing unit monitors an electrogram (EGM) signal and theprimary sensing channel applies a primary threshold to the EGM signal todetect sense events within the EGM signal. The secondary sensing channelapplies a secondary threshold to the EGM signal to detect under-sensedevents within the EGM signal. The processor detects at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel, wherein the processor determines whether the detectedbradycardia or asystole is false based on detection of under-sensedevents by the secondary sensing threshold.

According to another exemplary embodiment, a medical device comprises asensing unit, a primary sensing channel, a processor, and a memory unit.The sensing unit monitors an electrogram (EGM) signal and the primarysensing channel applies a primary threshold to the EGM signal to detectsense events within the EGM signal. The processor detects at least oneof bradycardia or asystole based on sense events detected by the primarysensing channel. The memory unit stores EGM segments associated with adetected bradycardia or asystole, wherein the processor determineswhether the detected bradycardia or asystole is false by applying asecondary threshold to the stored EGM segments to detect under-sensedevents in the EGM segments.

According to another exemplary embodiment, a medical device comprises ameans for sensing an electrogram (EGM) signal. The medical devicefurther comprises means for comparing an amplitude of the EGM signal toa primary threshold to sense events in the EGM signal and means fordetecting at least one of a bradycardia or an asystole based on thesensed events. The medical device further includes means for comparingthe EGM signal to a secondary threshold to sense events under-sensed bythe primary threshold in response to detecting at least one of abradycardia or an asystole. The medical device further includes meansfor determining whether the detection of the bradycardia or the asystoleis false based on the detection of under-sensed events.

According to another exemplary embodiment, an insertable cardiac monitorincludes a first electrode, second electrode, sensing unit, a primarysensing channel, a secondary sensing channel, and a processor. The firstelectrode is located at a distal end of the insertable cardiac monitorand the second electrode located at a proximal end of the insertablecardiac monitor. The sensing unit is coupled to the first and secondelectrode to monitor an electrogram (EGM) signal. The primary sensingchannel applies a primary threshold to the EGM signal to detect senseevents within the EGM signal, and the processor detects at least one ofbradycardia or asystole based on sense events detecting by the primarysensing channel. The secondary sensing channel applies a secondarythreshold to the EGM signal to detect under-sensed events within the EGMsignal, and the processor determines whether the detected bradycardia orasystole is false based on detection of under-sensed events by thesecondary sensing threshold.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic diagram of an exemplary medical device fordetecting a bradycardia/asystole event according to an embodiment of thepresent disclosure.

FIG. 2 is a functional schematic diagram of the medical device of FIG. 1according to an embodiment of the present disclosure.

FIG. 3 is a schematic diagram of an exemplary insertable cardiac monitorfor detecting a bradycardia/asystole event according to anotherembodiment of the present disclosure.

FIG. 4 is a conceptual diagram of an example of an exemplary insertablecardiac monitor for detecting a bradycardia/asystole event according toanother embodiment of the present disclosure.

FIG. 5 is a flowchart of a method of detecting and validatingbradycardia/asystole events according to an embodiment of the presentinvention.

FIG. 6 is a functional schematic diagram of an embodiment that utilizesfirst and second channels to detect and validate bradycardia/asystoleevents according to an embodiment of the present invention.

FIG. 7A illustrates an example EGM signal that includes PVC beats; FIG.7B illustrates analysis of the example EGM signal in a first channel andresulting under-sensing of the PVC beats; and FIG. 7C illustratesanalysis of the example EGM signal in a second channel to detect theunder-sensed PVC beats.

FIG. 8 is a functional schematic diagram of an embodiment that utilizesfirst and second channels to detect and validate bradycardia/asystoleevents according to another embodiment of the present invention.

FIG. 9 is a flowchart of a method of detecting and validatingbradycardia detections utilizing a first and second channel according toan embodiment of the present invention.

10A illustrates an example EGM signal that includes a PVC beat; FIG. 10Billustrates analysis of the example EGM signal in a first channel andresulting under-sensing of the PVC beat; and FIG. 10C illustratesanalysis of the example EGM signal using a secondary threshold to detectthe under-sensed PVC beat.

FIG. 11 is a flowchart of a method of detecting and validatingbradycardia detections utilizing a secondary threshold according to anembodiment of the present invention.

FIG. 12A illustrates an example EGM signal; FIG. 12B illustratesprocessing of the EGM signal within a first channel and resultingunder-sensing of ventricular events that results in an inappropriatepause/asystole detection; and FIG. 12C illustrates processing of the EGMsignal using a secondary threshold and secondary timer to detect theunder-sensed ventricular events and reject the detected pause/asystoledetection according to an embodiment of the present invention.

FIG. 13 is a flowchart of a method of detecting and validatingpause/asystole intervals utilizing a secondary threshold and secondarytimer according to an embodiment of the present invention.

DETAILED DESCRIPTION

A variety of medical devices monitor electrogram (EGM) signals of apatient to detect cardiac depolarizations. Based on the monitored EGMsignals, the device detects various types of arrhythmias such asfibrillation, tachycardia, bradycardia, and asystole. The term EGM isused herein to refer to any signal received by the medical device viaelectrodes that indicates electrical activity, e.g., depolarizations andrepolarization, of a heart, and may also be referred to aselectrocardiogram (ECG) signals. Furthermore, the term “sensed event” isutilized herein to refer to a detected depolarization/repolarization,which may include P-waves, R-waves (included as part of a QRS complex),and T-waves. In general, sensed events refer to detected R-wavesutilized to calculate R-R intervals for bradycardia/asystole detection.

Failure of the monitoring device to detect a sensed event (e.g., R-wave)may cause the monitoring device to inappropriately detect a bradycardiaor asystole. This failure to detect a sensed event is referred to asunder-sensing and may be a result of a variety of factors. For example,in one embodiment the threshold utilized to detect sense events is anauto-adjusting threshold that varies based on the amplitude of apreviously sensed event. For example, the auto-adjust threshold may beset to a relatively high value following a detected sense event having alarge amplitude, such that subsequent, lower amplitude sense events maybe under-sensed. This situation could arise in response to a prematureventricular contraction (PVC) having a very large QRS amplitude,followed by an R-wave characterized by normal QRS amplitudes. In anotherexample, PVCs characterized by a wide QRS complex result in the PVCbeats being under-sensed as a result of the low frequency contentassociated with the wide QRS complex. In yet another example, small andwide QRS complexes may result in under-sensing.

Depending on the type of medical device, in some cases the deviceprovides information regarding detection of arrhythmias, e.g., asystoleand bradycardia, for analysis by a clinician. The clinician may makediagnoses of conditions of a patient and, in some cases, prescribetherapy based on the information. A falsely-detected asystole orbradycardia may result in unnecessary delivery of stimulation to apatient by a medical device (e.g., cardiac pacing by a pacemaker). Insome cases, a falsely-detected asystole or bradycardia by a medicaldevice may result in inaccurate diagnosis of a patient condition by aclinician who reviews data regarding detection of asystole orbradycardia by the medical device, which in turn may result inunnecessary prescription of a therapy, e.g., pharmaceutical or a deviceto provide pacing.

In general, this disclosure is directed to signal processing-basedtechnique to prevent the inappropriate detection of bradycardia orasystole without compromising the detection of other arrhythmias(including properly identified bradycardia or asystole). In particular,the disclosure utilizes a first/primary channel to sense events (e.g.,R-waves). Based on events sensed in the primary channel, arrhythmicepisodes are detected including for example bradycardia and asystoleepisodes. In response to detection of at least one of a bradycardia orasystole episode, a secondary threshold is utilized to detect senseevents under-sensed by the first channel. A bradycardia or asystoleepisode detected in the first channel is verified based on eventsdetected in the second channel or using a secondary threshold. Asdescribed in more detail below, the signal-processing may be implementedin hardware, firmware, or a combination thereof. For example, anexemplary embodiment implemented in hardware may utilize a first channelcharacterized by a first auto-correct threshold to sense events, and asecond channel characterized by a second auto-correct threshold to senseevents under-sensed by the first channel. The events (e.g., R-waves)sensed by the first and second channels are combined to determinewhether a bradycardia or asystole detected in the first channel wasappropriate. In an exemplary embodiment implemented in firmware, an EGMsample in which a bradycardia or asystole episode is detected is storedto memory and analyzed using a secondary threshold to detectunder-sensed events. A determination is then made whether thebradycardia or asystole is appropriate based on the events detectedusing the secondary threshold. In this way, the present disclosureprovides a signal-processing system and method for preventinginappropriate detection of bradycardia and/or asystole.

In the following description, references are made to illustrativeembodiments for carrying out the methods described herein. It isunderstood that other embodiments may be utilized without departing fromthe scope of the disclosure. The methods presented herein may beembodied in software, hardware, firmware or combinations thereof inimplantable or external medical devices. Such devices includeimplantable monitoring devices having cardiac electrogram(EGM)/electrocardiogram (ECG) monitoring capabilities and associatedEGM/ECG sense electrodes, which may be intracardiac, epicardial, orsubcutaneous electrodes. The methods described herein can also beincorporated in implantable medical devices having therapy deliverycapabilities, such as single chamber or bi ventricular pacing systems orICDs that sense the R-waves in the ventricles and deliver an electricalstimulation therapy to the ventricles. The bradycardia/asystoledetection and verification methods presently disclosed may also beincorporated in external monitors having ECG electrodes coupled to thepatient's skin to detect R-waves, e.g. Holter monitors, or withincomputerized systems that analyze prerecorded ECG or EGM data.Embodiments may further be implemented in a patient monitoring system,such as a centralized computer system which processes data sent to it byimplantable or wearable monitoring devices, including subcutaneousdevices having loop recorders.

FIG. 1 is a schematic diagram of an exemplary medical device fordetecting an arrhythmia according to an embodiment of the presentdisclosure. As illustrated in FIG. 1, an implantable medical device 100according to an embodiment of the present disclosure may be in the formof an implantable cardioverter defibrillator (ICD) 100 that includesconnector block 102 that receives the proximal ends of a rightventricular lead 104, a right atrial lead 106 and a coronary sinus lead108, used for positioning electrodes for sensing and stimulation inthree or four heart chambers. Right ventricular lead 104 is positionedsuch that its distal end is in the right ventricle for sensing rightventricular cardiac signals and delivering pacing or shocking pulses inthe right ventricle. For these purposes, right ventricular lead 104 isequipped with a ring electrode 110, an extendable helix electrode 112mounted retractably within an electrode head 114, and a coil electrode116, each of which are connected to an insulated conductor within thebody of lead 104. The proximal end of the insulated conductors arecoupled to corresponding connectors carried by bifurcated connector 118at the proximal end of lead 104 for providing electrical connection tothe ICD 100. It is understood that although the device illustrated inFIG. 1 is a dual chamber device, other devices such as single chamberdevices may be utilized to perform the technique of the presentdisclosure described herein.

The right atrial lead 106 is positioned such that its distal end is inthe vicinity of the right atrium and the superior vena cava. Lead 106 isequipped with a ring electrode 120 and an extendable helix electrode122, mounted retractably within electrode head 124, for sensing andpacing in the right atrium. Lead 106 is further equipped with a coilelectrode 126 for delivering high-energy shock therapy. The ringelectrode 120, the helix electrode 122 and the coil electrode 126 areeach connected to an insulated conductor with the body of the rightatrial lead 106. Each insulated conductor is coupled at its proximal endto a connector carried by bifurcated connector 128.

The coronary sinus lead 108 is advanced within the vasculature of theleft side of the heart via the coronary sinus and great cardiac vein.The coronary sinus lead 108 is shown in the embodiment of FIG. 1 ashaving a defibrillation coil electrode 130 that may be used incombination with either the coil electrode 116 or the coil electrode 126for delivering electrical shocks for cardioversion and defibrillationtherapies. In other embodiments, coronary sinus lead 108 may also beequipped with a distal tip electrode and ring electrode for pacing andsensing functions in the left chambers of the heart. The coil electrode130 is coupled to an insulated conductor within the body of lead 108,which provides connection to the proximal connector 132.

The electrodes 122 and 120 or 110 and 112 may be used as true bipolarpairs, commonly referred to as a “tip-to-ring” configuration. Further,electrode 122 and coil electrode 116 or electrode 110 and coil electrode126 may be used as integrated bipolar pairs, commonly referred to as a“tip-to-coil” configuration. In accordance with the invention, ICD 100may, for example, adjust the electrode configuration from a tip-to ringconfiguration, e.g., true bipolar sensing, to a tip-to-coilconfiguration, e.g., integrated bipolar sensing, upon detection ofoversensing in order to reduce the likelihood of future oversensing. Inother words, the electrode polarities can be reselected in response todetection of oversensing in an effort to reduce susceptibility ofoversensing. In some cases, electrodes 122, 120, 110, and 112 may beused individually in a unipolar configuration with the device housing134 serving as the indifferent electrode, commonly referred to as the“can” or “case” electrode.

The device housing 134 may also serve as a subcutaneous defibrillationelectrode in combination with one or more of the defibrillation coilelectrodes 130, 116 or 126 for defibrillation of the atria orventricles. It is recognized that alternate lead systems may besubstituted for the three lead system illustrated in FIG. 1. While aparticular multi-chamber ICD and lead system is illustrated in FIG. 1,methodologies included in the present invention may adapted for use withany single chamber, dual chamber, or multi-chamber ICD or pacemakersystem, subcutaneous implantable device, or other internal or externalcardiac monitoring device.

ICD 100 may alternatively be configured as a subcutaneous device havingsensing or pacing electrodes incorporated on the housing 134 of thedevice in which case transvenous leads are not required. A subcutaneousdevice may be coupled to a lead tunneled subcutaneously or submuscularlyfor delivering transthoracic pacing pulses and/or sensing ECG signals.An exemplary subcutaneous device is described in commonly assigned U.S.patent application Ser. Nos. 14/604,111 and 14/604,260, bothincorporated herein by reference in their entireties. The techniquesdescribed herein can also be implemented in an external device, e.g.including patch electrodes and optionally another physiological sensorif desired, that can sense variable parameters as described herein.

FIG. 2 is a functional schematic diagram of the medical device ofFIG. 1. This diagram should be taken as exemplary of the type of devicewith which the invention may be embodied and not as limiting. Thedisclosed embodiment shown in FIG. 2 is a microprocessor-controlleddevice, but the methods of the present invention may also be practicedwith other types of devices such as those employing dedicated digitalcircuitry.

With regard to the electrode system illustrated in FIG. 1, ICD 100 isprovided with a number of connection terminals for achieving electricalconnection to the leads 104, 106, and 108 and their respectiveelectrodes. A connection terminal 200 provides electrical connection tothe housing 134 for use as the indifferent electrode during unipolarstimulation or sensing. The connection terminals 202, 204, and 206provide electrical connection to coil electrodes 116, 130 and 126respectively. Each of these connection terminals 200, 202, 204, and 206are coupled to the high voltage output circuit 208 to facilitate thedelivery of high energy shocking pulses to the heart using one or moreof the coil electrodes 116, 126, and 130 and optionally the housing 134.

The connection terminals 210 and 212 provide electrical connection tothe helix electrode 122 and the ring electrode 120 positioned in theright atrium. The connection terminals 210 and 212 are further coupledto an atrial sense amplifier 214 for sensing atrial signals such asP-waves. The connection terminals 216 and 218 provide electricalconnection to the helix electrode 112 and the ring electrode 110positioned in the right ventricle. The connection terminals 216 and 219are further coupled to a first ventricular sense amplifier 220 forsensing ventricular signals (i.e., a first ventricular sensing channel).In one embodiment, first ventricular sense amplifier 220 ischaracterized by a first auto-adjust threshold utilized to senseventricular events, in particular R-waves (illustrated by the outputR_(OUT1)) In one embodiment, a second ventricular sense amplifier 222 isalso connected to connection terminals 216 and 219 for sensingventricular events. In one embodiment, second amplifier 222 ischaracterized by a second auto-adjust threshold utilized to detectventricular events (e.g., R-waves) under-sensed by the first ventricularsense amplifier 222 (illustrated by the output R_(OUT2)). Described inmore detail below, this requires the second ventricular sense amplifier222 to implement a different sensing threshold than the firstventricular sense amplifier 220.

The atrial sense amplifier 214 and the ventricular sense amplifiers 220and 222 preferably take the form of automatic gain controlled amplifierswith adjustable sensitivity. In accordance with the invention, ICD 100and, more specifically, microprocessor 224 maintains the sensitivity ofthe second ventricular sense amplifier 222 to be lower than that offirst ventricular sense amplifier such that second ventricular senseamplifier 222 is able to detect events under-sensed by first ventricularsense amplifier 220. In addition, atrial sense amplifier 214 and firstand second ventricular sense amplifiers 220 and 222 receive timinginformation from pacer timing and control circuitry 226. Specifically,atrial sense amplifier 214 and first and second ventricular senseamplifiers 220 and 222 receive blanking period input, e.g., ABLANK,VBLANK1, and VBLANK2 respectively, which indicates the amount of timethe electrodes are “turned off” in order to prevent saturation due to anapplied pacing pulse or defibrillation shock. As will be described, theblanking periods first and second ventricular sense amplifiers 220 and222 and, in turn, the blanking periods of sensing electrodes associatedwith the respective amplifiers may be automatically adjusted by ICD 100to reduce the likelihood of sensing cardiac events outside of thedesired R-waves (for example, P-waves and T-waves). The generaloperation of the ventricular sense amplifiers 220 and 222 and the atrialsense amplifier 214 may correspond to that disclosed in U.S. Pat. No.5,117,824, by Keimel, et al., incorporated herein by reference in itsentirety. Whenever a signal received by atrial sense amplifier 214exceeds an atrial sensitivity, a signal is generated on the P-out signalline. Whenever a signal received by the ventricular sense amplifier 220exceeds a first ventricular sensitivity, a signal is generated on theR_(OUT1) signal line, and whenever a signal received by the ventricularsense amplifier 222 exceeds a second ventricular sensitivity, a signalis generated on the R_(OUT2) signal line. As described in more detailbelow, bradycardia or asystole detected based on R-waves sensed by thefirst ventricular sense amplifier 220 are verified based on whether ornot additional R-waves—under-sensed by the first ventricular senseamplifier 220—are sensed by second ventricular sense amplifier 222.

Switch matrix 228 is used to select which of the available electrodesare coupled to a wide band amplifier 230 for use in digital signalanalysis. Selection of the electrodes is controlled by themicroprocessor 224 via data/address bus 232. The selected electrodeconfiguration may be varied as desired for the various sensing, pacing,cardioversion and defibrillation functions of the ICD 100.

Signals from the electrodes selected for coupling to bandpass amplifier230 are provided to multiplexer 234, and thereafter converted tomulti-bit digital signals by A/D converter 236, for storage in randomaccess memory 238 under control of direct memory access circuit 240 viadata/address bus 232. Microprocessor 224 may employ digital signalanalysis techniques to characterize the digitized signals stored inrandom access memory 238 to recognize and classify the patient's heartrhythm employing any of the numerous signal processing methodologiesknown in the art. In one embodiment (described in more detail withrespect to FIGS. 10A-11), EGM data stored in RAM 238 is analyzed inresponse to bradycardia or asystole detected by first ventricularamplifier 220 to determine whether the detected bradycardia or asystoleis appropriate. This embodiment, implemented in firmware, does notrequire a second sensing channel (i.e., second ventricular amplifier222). Rather, the stored EGM data is analyzed using a secondarythreshold to detect events under-sensed by the first ventricularamplifier 220. Detection and verification of the bradycardia or asystoleresults in an episode of EGM data, along with sensed intervals andcorresponding annotations of sensed events, are preferably stored inrandom access memory 238.

The telemetry circuit 242 receives downlink telemetry from and sendsuplink telemetry to an external programmer, as is conventional inimplantable anti-arrhythmia devices, by means of an antenna 244. Data tobe uplinked to the programmer and control signals for the telemetrycircuit are provided by microprocessor 224 via address/data bus 232. EGMdata that has been stored upon arrhythmia detection (i.e., bradycardiaor asystole) or as triggered by other monitoring algorithms may beuplinked to an external programmer using telemetry circuit 242. Receivedtelemetry is provided to microprocessor 224 via multiplexer 234.Numerous types of telemetry systems known in the art for use inimplantable devices may be used.

The remainder of the circuitry illustrated in FIG. 2 is an exemplaryembodiment of circuitry dedicated to providing cardiac pacing,cardioversion and defibrillation therapies. The pacer timing and controlcircuitry 226 includes programmable digital counters which control thebasic time intervals associated with various single, dual ormulti-chamber pacing modes or anti-tachycardia pacing therapiesdelivered in the atria or ventricles. Pacer circuitry 226 alsodetermines the amplitude of the cardiac pacing pulses under the controlof microprocessor 224.

During pacing, escape interval counters within pacer timing and controlcircuitry 226 are reset upon sensing of R-waves or P-waves as indicatedby the output of amplifiers 214, 220 and 222, respectively. Inaccordance with the selected mode of pacing, pacing pulses are generatedby atrial pacer output circuit 244 and ventricular pacer output circuit246. The pacer output circuits 244 and 246 are coupled to the desiredelectrodes for pacing via switch matrix 228. The escape intervalcounters are reset upon generation of pacing pulses, and thereby controlthe basic timing of cardiac pacing functions, including anti-tachycardiapacing. As discussed in more detail with respect to FIGS. 12A-13, asecondary timer may be utilized to verify a detected asystole episode.In particular, in response to a detected asystole by the primary sensingchannel, a secondary timer is initialized and the detected asystole isanalyzed using a secondary threshold. The secondary timer continues toincrement unless an under-sensed event is detected by the secondarythreshold, in which case the secondary timer is reset. Followinganalysis of the detected asystole episode with the secondary threshold,the secondary timer is utilized to determine if the asystole detectionwas appropriate.

The microprocessor 224 includes associated read-only memory (ROM) inwhich stored programs controlling the operation of the microprocessor224 reside. For example, the embodiment described with respect to FIGS.10A-13, which implements an embodiment of the present invention infirmware, would be implemented with programs stored in the ROM ofmicroprocessor 224. A portion of the random access memory (RAM) 238 maybe configured as a number of recirculating buffers capable of holding aseries of measured intervals for analysis by the microprocessor 224 forverifying a detected bradycardia or asystole.

In the event that higher voltage cardioversion or defibrillation pulsesare required, microprocessor 224 activates the cardioversion anddefibrillation control circuitry 248 to initiate charging of the highvoltage capacitors 250 and 252 via charging circuit 254 under thecontrol of high voltage charging control line 256. The voltage on thehigh voltage capacitors is monitored via a voltage capacitor (VCAP) line258, which is passed through the multiplexer 220. When the voltagereaches a predetermined value set by microprocessor 224, a logic signalis generated on the capacitor full (CF) line 260, terminating charging.The defibrillation or cardioversion pulse is delivered to the heartunder the control of the pacer timing and control circuitry 226 by theoutput circuit 208 via a control bus 262. The output circuit 208determines the electrodes used for delivering the cardioversion ordefibrillation pulse and the pulse wave shape.

FIG. 3 is a conceptual diagram of an example of an insertable cardiacmonitor 300 for detecting a bradycardia/asystole event, according toanother embodiment of the present disclosure. In the embodiment shown inFIG. 3, insertable cardiac monitor 300 may be embodied as a monitoringdevice having housing 302, proximal electrode 304 and distal electrode306. Housing 302 may further comprise first major surface 308, secondmajor surface 310, proximal end 312, and distal end 314. Housing 302encloses electronic circuitry 400 and power source 402 (shown in FIG. 4)located inside the insertable cardiac monitor 300 and protects thecircuitry contained therein from body fluids. Electrical feedthroughsprovide electrical connection of electrodes 304 and 306.

In the embodiment shown in FIG. 3, insertable cardiac monitor 300 isdefined by a length L, a width W and thickness or depth D and is in theform of an elongated rectangular prism wherein the length L is muchlarger than the width W, which in turn is larger than the depth D. Inone embodiment, the geometry of the insertable cardiac monitor 300—inparticular a width W greater than the depth D—is selected to allow thecardiac monitor 300 to be inserted under the skin of the patient using aminimally invasive procedure and to remain in the desired orientationduring insert. For example, the device shown in FIG. 3 includes radialasymmetries (notably, the rectangular shape) along the longitudinal axisthat maintains the device in the proper orientation following insertion.For example, in one embodiment the spacing between proximal electrode304 and distal electrode 306 may range from 30 millimeters (mm) to 55mm, 35 mm to 55 mm, and from 40 mm to 55 mm and may be any range orindividual spacing from 25 mm to 60 mm. In addition, insertable cardiacmonitor 300 may have a length L that ranges from 30 mm to about 70 mm.In other embodiments, the length L may range from 40 mm to 60 mm, 45 mmto 60 mm and may be any length or range of lengths between about 30 mmand about 70 mm. In addition, the width W of major surface 308 may rangefrom 3 mm to 10 mm and may be any single or range of widths between 3 mmand 10 mm. The thickness of depth D of cardiac monitor device 300 mayrange from 2 mm to 9 mm. In other embodiments, the depth D of insertablecardiac monitor 300 may range from 2 mm to 5 mm and may be any single orrange of depths from 2 mm to 9 mm. In addition, insertable cardiacmonitor 300 according to an embodiment of the present invention is has ageometry and size designed for ease of implant and patient comfort.Embodiments of insertable cardiac monitor 300 described in thisdisclosure may have a volume of three cubic centimeters (cm) or less,1.5 cubic cm or less or any volume between three and 1.5 cubiccentimeters.

In the embodiment shown in FIG. 3, once inserted within the patient, thefirst major surface 308 faces outward, toward the skin of the patientwhile the second major surface 310 is located opposite the first majorsurface 308. In addition, in the embodiment shown in FIG. 3, proximalend 312 and distal end 314 are rounded to reduce discomfort andirritation to surrounding tissue once inserted under the skin of thepatient. Insertable cardiac monitor 300, including instrument and methodfor inserting monitor 300 is described, for example, in U.S. PatentPublication No. 2014/0276928, incorporated herein by reference in itsentirety.

As described with other embodiments, proximal electrode 304 and distalelectrode 306 are used to sense cardiac signals for determining abradycardia or asystole event, described below, e.g. ECG signals,intra-thoracically or extra-thoracically, which may be sub-muscularly orsubcutaneously. ECG signals may be stored in a memory of the insertablecardiac monitor 300, and ECG data may be transmitted via integratedantenna 322 to another medical device, which may be another implantabledevice or an external device. In alternative applications, electrodes304 and 306 may be used for sensing any bio-potential signal ofinterest, which may be, for example, an EGM, EEG, EMG, or a nervesignal, from any implanted location.

In the embodiment shown in FIG. 3, proximal electrode 304 is in closeproximity to the proximal end 312 and distal electrode 306 is in closeproximity to distal end 314. In this embodiment, distal electrode 306 isnot limited to a flattened, outward facing surface, but may extend fromfirst major surface 308 around rounded edges 316 and/or end surface 318and onto the second major surface 310 so that the electrode 306 has athree-dimensional curved configuration. In the embodiment shown in FIG.3, proximal electrode 304 is located on first major surface 308 and issubstantially flat, outward facing. However, in other embodimentsproximal electrode 304 may utilize the three dimensional curvedconfiguration of distal electrode 306, providing a three dimensionalproximal electrode (not shown in this embodiment). Similarly, in otherembodiments distal electrode 306 may utilize a substantially flat,outward facing electrode located on first major surface 308 similar tothat shown with respect to proximal electrode 304. The various electrodeconfigurations allow for configurations in which proximal electrode 304and distal electrode 306 are located on both first major surface 308 andsecond major surface 310. In other configurations, such as that shown inFIG. 3, only one of proximal electrode 304 and distal electrode 306 islocated on both major surfaces 308 and 310, and in still otherconfigurations both proximal electrode 304 and distal electrode 306 arelocated on one of the first major surface 308 or the second majorsurface 310 (i.e., proximal electrode 304 located on first major surface308 while distal electrode 306 is located on second major surface 310).In another embodiment, cardiac monitor device 300 may include electrodeson both major surface 308 and 310 at or near the proximal and distalends of the device, such that a total of four electrodes are included oncardiac monitor device 300. Electrodes 304 and 306 may be formed of aplurality of different types of biocompatible conductive material, e.g.stainless steel, titanium, platinum, iridium, or alloys thereof, and mayutilize one or more coatings such as titanium nitride or fractaltitanium nitride.

In the embodiment shown in FIG. 3, proximal end 312 includes a headerassembly 320 that includes one or more of proximal electrode 304,integrated antenna 322, anti-migration projections 324, and/or suturehole 326. Integrated antenna 322 is located on the same major surface(i.e., first major surface 308) as proximal electrode 304 and is alsoincluded as part of header assembly 320. Integrated antenna 322 allowsinsertable cardiac monitor 300 to transmit and/or receive data. In otherembodiments, integrated antenna 322 may be formed on the opposite majorsurface as proximal electrode 304, or may be incorporated within thehousing 322 of insertable cardiac monitor 300. In the embodiment shownin FIG. 3, anti-migration projections 324 are located adjacent tointegrated antenna 322 and protrude away from first major surface 308 toprevent longitudinal movement of the device. In the embodiment shown inFIG. 3, anti-migration projections 324 includes a plurality (e.g., nine)small bumps or protrusions extending away from first major surface 308.As discussed above, in other embodiments anti-migration projections 324may be located on the opposite major surface as proximal electrode 304and/or integrated antenna 322. In addition, in the embodiment shown inFIG. 3 header assembly 320 includes suture hole 326, which providesanother means of securing insertable cardiac monitor 300 to the patientto prevent movement following insert. In the embodiment shown, suturehole 326 is located adjacent to proximal electrode 304. In oneembodiment, header assembly 320 is a molded header assembly made from apolymeric or plastic material, which may be integrated or separable fromthe main portion of insertable cardiac monitor 300.

FIG. 4 is a functional schematic diagram of the insertable cardiacmonitor 300 as shown in FIG. 3 according to an embodiment of the presentdisclosure. Insertable cardiac monitor 300 includes housing 302,proximal electrode 304 located at proximal end 312, distal electrode 306located at distal end 314, integrated antenna 322, electrical circuitry400 and power source 402. In particular, electrical circuitry 400 iscoupled to proximal electrode 304 and distal electrode 306 to sensecardiac signals and monitor events, including bradycardia and asystoleas described in more detail below. Electrical circuitry 400 is alsoconnected to transmit and receive communications via integrated antenna322. Power source 402 provides power to electrical circuitry 400, aswell as to any other components that require power. Power source 402 mayinclude one or more energy storage devices, such as one or morerechargeable or non-rechargeable batteries. The insertable cardiacmonitor 300 as shown in FIGS. 3 and 4 is a monitoring-only device.However, in other examples, insertable cardiac monitor 300 may furtherprovide therapy delivery capabilities as described with respect to FIGS.1-2.

In the embodiment shown in FIG. 4, electrical circuitry 400 receives rawEGM signals monitored by proximal electrode 304 and distal electrode306. Electrical circuitry 400 includes components/modules for convertingthe raw EGM signal to a processed EGM signal that can be analyzed todetect sense events. Although not shown, electrical circuitry 400 mayinclude any discrete and/or integrated electronic circuit componentsthat implement analog and/or digital circuits capable of producing thefunctions described for analyzing EGM signals to detect/verifybradycardia and/or asystole events. For example, the electricalcircuitry 400 may include analog circuits, e.g., pre-amplificationcircuits, filtering circuits, and/or other analog signal conditioningcircuits (such as those shown with respect to FIG. 2). The modules mayalso include digital circuits, e.g., digital filters, combinational orsequential logic circuits, state machines, integrated circuits, aprocessor (shared, dedicated, or group) that executes one or moresoftware or firmware programs, memory devices, or any other suitablecomponents or combination thereof that provide the describedfunctionality.

In one embodiment electrical circuitry 400 includes a sensing unit formonitoring the EGM signal detected by the respective proximal and distalelectrodes 304 and 306, respectively, and at least a primary sensingchannel that utilizes a first threshold for sensing events in the EMGsignal. Sensed events (e.g., R-waves) are utilized to detect at leastone of bradycardia or asystole episodes. In one embodiment, electricalcircuitry 400 includes a processor is utilized to receive informationregarding the sensed events and implements one or more algorithms fordetermining whether a bradycardia/asystole event has occurred. Inaddition, electrical circuitry 400 may further include a secondarychannel and/or threshold used to detect sense events under-sensed by thefirst threshold. The results of which are utilized (for example, by theprocessor) to verify the bradycardia sense or asystole sense. Inaddition, the analog voltage signals received from electrodes 304 and306 may be passed to analog-to-digital (A/D) converters included in theelectrical circuitry 400, and stored in a memory unit (not shown)included as part of electrical circuitry 400 for subsequent analysiswith firmware executed by the processor included as part of electricalcircuitry 400. This additional analysis may also include comparison ofthe EGM signal to a secondary threshold to detect sense eventsunder-sensed by the first threshold.

Electrical circuitry 400 controls insertable cardiac monitor 300functions and processes EGM signals received from electrodes 304 and 306according to programmed signal analysis routines or algorithms. Theinsertable cardiac monitor 300 may include other optional sensors (notshown) for monitoring physiological signals, such as an activity sensor,pressure sensor, oxygen sensor, accelerometer, or other sensor used tomonitor a patient. These may also be provided to electrical circuitry400 for processing.

Electrical circuitry 400 may similarly control monitoring time intervalsand sampling rates according to a particular clinical application. Inaddition, electrical circuitry may include state machines or othersequential logic circuitry to control device functions and need not beimplemented exclusively as a microprocessor. For example, electricalcircuitry 400 may include timers utilized to detect asystole events asdescribed in more detail below.

Electrical circuity 400 communicates with integrated antenna 322 (shownin FIG. 3) to transmit electrical signal data, e.g. ECG signal data,stored in memory or received from electrical circuitry 400 in real time.Antenna 322 may be configured to transmit and receive communicationsignals via inductive coupling, electromagnetic coupling, tissueconductance, Near Field Communication (NFC), Radio FrequencyIdentification (RFID), BLUETOOTH®, WiFi, or other proprietary ornon-proprietary wireless telemetry communication schemes. Communicationmodule enables the insertable cardiac monitor 300 to communicate with aprogrammer (not shown) located external to the device 300 and includes auser interface that presents information to and receives input from auser. It should be noted that the user may also interact with programmerremotely via a networked computing device.

A user, such as a physician, technician, surgeon, electrophysiologist,other clinician, or patient, interacts with programmer to communicatewith insertable cardiac monitor 300. For example, the user may interactwith programmer to retrieve physiological or diagnostic information fromcardiac monitor 300. A user may also interact with programmer to programcardiac monitor 300, e.g., select values for operational parameters ofthe cardiac monitor 300. For example, the user may use programmer toretrieve information from cardiac monitor 300 regarding the rhythm of apatient heart, trends therein over time, or arrhythmic episodes. Cardiacmonitor 300 and the programmer may communicate via wirelesscommunication using any techniques known in the art.

Depiction of different features as modules is intended to highlightdifferent functional aspects and does not necessarily imply that suchmodules must be realized by separate hardware or software components.Rather, functionality associated with one or more modules may beperformed by separate hardware, firmware and/or software components, orintegrated within common hardware, firmware and/or software components.

Inappropriate Bradycardia Detection

As discussed above, the presence of irregular cardiac (specificallyventricular) depolarizations such as premature ventricular contractions(PVCs) can lead to the under-sensing of events by the detection methodstypically employed by monitoring devices. The under-sensing of eventsresults in the monitoring system incorrectly identifying bradycardia orasystole events. FIG. 5 describes a method and system for verifyingbradycardia and/or asystole episodes based on the detection ofunder-sensed events. FIGS. 6-11 describe a method and system fordetecting inappropriate bradycardia specifically, and FIGS. 12A-13describe a method and system for detecting inappropriate asystolespecifically.

FIG. 5 is a flowchart of method 500 of detecting and validatingbradycardia and asystole episodes according to an embodiment of thepresent invention. At step 501, signals indicative of cardiac activity(e.g., electrogram (EGM), electrocardiogram (ECG), etc.) are sensed. Asdescribed with respect to FIGS. 1-4, a plurality of device/electrodeconfigurations may be utilized to monitor EGM/ECG signals. At step 502,sense events (e.g., R-waves) are detected utilizing a firstchannel/threshold. For example, in one embodiment an R-wave is sensedeach time the monitored electrogram (EGM) signal exceeds a firstthreshold. As described in more detail with respect to FIGS. 6A and 6B,the first threshold utilized at step 502 may be an auto-adjustedthreshold that varies based on one or more factors to avoid oversensingevents in the EGM signal, such as T-waves and P-waves.

At step 504, the interval between sensed events—including both R-wavesand escape beats—are utilized to detect at least one of bradycardia orasystole episodes. For example, a bradycardia sense is detected if theinterval between successive R-waves (i.e., the R-R interval) is greaterthan a bradycardia interval. Consecutive detection of bradycardia sensefor a number of beats (e.g., four) leads to a bradycardia episodedetection. Likewise, an asystole episode may be detected based on alonger interval between sensed events (which may include an escapebeat). If no bradycardia or asystole is detected at step 504, then themethod continues at step 501 with monitoring of cardiac activity.However, if a bradycardia sense or asystole episode is detected, thenthe method continues at steps 506-510 to determine whether the detectionof bradycardia/asystole episode is appropriate.

In particular, at step 506 a second threshold is calculated/selected todetect events that may have been under-sensed by the first threshold.The second threshold is therefore calculated and/or selected to be moresensitive than the first threshold. As discussed in more detail below,the second threshold may be calculated in a variety of ways. In oneembodiment, the second threshold is calculated based on the amplitude ofsensed events. In each case, however, the purpose of the secondthreshold is to detect events under-sensed by the first threshold.

At step 508 the second threshold is applied to the EGM segment thatresulted in the bradycardia or asystole detection. Previouslyunder-sensed events are detected in response to the EGM signal exceedingthe second threshold value. At step 510, the detected bradycardia orasystole episode is either confirmed or rejected based on eventsdetected via application of the second threshold. For example, if anevent under-sensed by the first threshold is sensed by the secondthreshold, and the under-sensed event results in no R-R interval beinggreater than the bradycardia interval, then the bradycardia sense eventis rejected. Conversely, if either no under-sensed events are detected,or despite detection of under-sensed events the R-R interval remainsgreater than the bradycardia interval, the bradycardia sense event isconfirmed.

FIG. 6 is a functional schematic diagrams illustrating implementation ofdual sense channels according to embodiments of the present invention.In the embodiment shown in FIG. 6, first sensing channel 600 includespre-amplifier 602, band-pass filter 604, rectifier 606, andauto-adjusting threshold 608, while secondary sensing channel 610includes second auto-adjusting threshold 612. A raw EGM signal measuredby one or more electrodes is provided as an input to pre-amplifier 602.The combination of pre-amplifier, band-pass filter 604, and rectifier606 act to filter and rectify the raw EGM signal to reduce noise andimprove the quality of the EGM signal. The filtered/rectified EGM signalis provided to first auto-adjusting threshold 608. Events (e.g.,R-waves) are sensed in response to the received filtered/rectified EGMsignal exceeding the value of the first auto-adjusting threshold. Toavoid noise or other artifacts from triggering the sensing of an R-wave,the auto-adjusting threshold 608 decays from a maximum value following aprevious R-wave sense to a minimum or floor value. A graphicalrepresentation of the first auto-adjusting threshold 608 according to anembodiment of the present invention is illustrated in the region aboveauto-adjusting threshold box 608. In the embodiment shown in FIG. 6, theauto-adjusting threshold 608 is set to a value related to the amplitudeof the previously sensed R-wave (e.g., 65% of the previous amplitude),although in other embodiments this may be a predetermined value. Theauto-adjusting threshold 608 then decays gradually to a minimum or floorvalue (e.g., 35 μV). Although the first auto-adjusting threshold 608 isdesigned and optimized to correctly sense typical R-wavedepolarizations, in particular to avoid T-wave over-sensing, certaintypes of events such as PVCs may not be properly sensed by the firstauto-adjusting threshold 608 (a condition referred to as“under-sensing”). The under-sensing of these events may result in an R-Rinterval (i.e., the interval between consecutively sensed R-waves) thatindicates the patient is experiencing a bradycardia.

The secondary sensing channel 610 comprised of secondary auto-adjustingthreshold 612 is utilized validate (i.e., reject or accept) thedetection of bradycardia/asystole episodes by primary sensing channel600. In particular, secondary sensing channel 610 acts to detect thoseevents under-sensed by primary sensing channel 600. In the embodimentshown in FIG. 6, secondary auto-adjusting threshold 612 also decays froma maximum value to a minimum value or floor. In particular, thesecondary auto-adjusting threshold 612 is designed to decay quickly toallow for events such as PVCs to be detected. In the embodiment shown inFIG. 6, the maximum value of the auto-adjusting threshold 612 is relatedto the amplitude of the previously sensed event (e.g., 30% of the sensedamplitude). As compared with first auto-adjusting threshold 608, themaximum value of secondary auto-adjusting threshold 612 is lower, and istherefore more sensitive to under-sensed events. Following a blankingperiod, the secondary auto-adjusting threshold 612 decays rapidly to theminimum or floor value. In the embodiment shown in FIG. 6, the floorvalue is related to the amplitude of the previously sensed event (e.g.,12%), however, in other embodiments this value may be predetermined orprogrammable. In one embodiment, even if the floor value is related tothe amplitude of the previously sensed event (e.g., 12%), the floorvalue cannot decrease to a value less than the floor value utilized byprimary auto-adjusting threshold 608. In the embodiment shown in FIG. 6,the secondary auto-adjusting threshold 612 decays more rapidly to aminimum or floor value as compared with the primary auto-adjustingthreshold, which also improves the secondary auto-adjusting threshold612 sensitivity to under-sensed events. A blanking period may beutilized to maintain the secondary auto-adjusting threshold 612 at themaximum value for period of time, which may be predetermined orprogrammable (e.g., 500 ms in the embodiment shown in FIG. 6). Theblanking period prevents sensing events such as T-waves that immediatelyfollow R-wave senses.

In the embodiment shown in FIG. 6, a plurality of parameters define thebehavior of the secondary auto-adjusting threshold 612. These parametersmay be programmable and may be stored in hardware and/or software. Inone embodiment these parameters include the maximum value of theauto-adjust threshold (e.g., 30% of previously sense R-wave amplitude),duration of the blanking period following an R-wave sense before thethreshold begins to decrease or decay (e.g., 500 ms), the rate at whichthe threshold decreases or decays, and the minimum threshold value orfloor. In one embodiment, the maximum value is not allowed to exceed amaximum value (i.e., is clipped to a maximum value), which may also beprogrammable.

The output of primary sensing channel 600 and secondary sensing channel610 are utilized to determine whether a detected bradycardia/asystoleepisode was appropriate or not. In one embodiment, a processor (e.g.,microprocessor 224 in FIG. 2, or processing and control unit 404 in FIG.4) combines the outputs of primary sensing channel 600 and secondarysensing channel 610 and determines whether the detectedbradycardia/asystole was appropriate. For example, RR intervalsdetermined by dual channel sensing as not indicative of a bradycardiasense should be less than the bradycardia interval and greater than 200ms (typical value of PR interval to avoid p-wave undersensing).

FIG. 7A illustrates an electrogram (EGM) signal 700. FIG. 7B illustratesprocessing of the filtered and rectified EGM signal 702 by primarysensing channel and resulting bradycardia detect, and FIG. 7Cillustrates processing of the EGM signal within a second channel toverify/reject the detected bradycardia according to an embodiment of thepresent invention. With respect to FIG. 7A, the various types of sensedevents (e.g., R-waves, PVCs) are labeled to aid in understanding howunder-sensing of events by the primary sense channel results in improperbradycardia detection. In the example shown in FIG. 7A, the raw EGMsignal is characterized by bigeminal PVC beats. For example, R-waves R₃and R₄ are separated by a PVC beat (PVC₁). Likewise, R-waves R₄ and R₅are separated by PVC₂. This pattern continues with alternating R-wavesand PVC beats.

FIG. 7B illustrates comparison of the filtered/rectified EGM signal 702(solid black line) with the primary auto-adjusting threshold 706described with respect to FIG. 6. In this example, thefiltered/rectified R-waves are characterized by amplitudes higher thanthose of the filtered/rectified PVC beats. This is due, in part, to thelower-frequency content (i.e., wider QRS complex shape) of the PVCbeats, which when filtered results in a lower amplitudefiltered/rectified EGM signal. As a result of this lower amplitude, theembodiment shown in FIG. 7B illustrates how the primary sensingthreshold fails to detect the presence of the PVC beats (i.e., the PVCbeats are under-sensed). For example, following the sense of R-wave R₃,the primary sensing threshold is reset to a maximum value, and after abrief period of time begins decaying toward a minimum or floor value.However, the rate of the decay is not fast enough to detect the presenceof PVC₁. The same scenario occurs with respect to other PVC beats, witheach of PVC₁, PVC₂, PVC₃, PVC₄, PVC₅, and PVC₆ being under-sensed. As aresult of the under-sensing of PVC₁, the R-R interval 710 measuredbetween R-waves R₃ and R₄ is greater than the bradycardia interval,which results in an erroneous bradycardia sense (and possible erroneousdetection of a bradycardia episode if a plurality of inappropriatebradycardia senses are detected).

FIG. 7C illustrates how the erroneous bradycardia detection shown inFIG. 7B is remedied by the secondary auto-adjust sensing threshold 708.Notice that in response to each sensed event, secondary auto-adjustsensing threshold is reset to a maximum value that is related to themagnitude of the previously sensed event. The secondary auto-adjustsensing threshold 708 remains at the maximum value for a period of time(i.e., predetermined blanking period) before decreasing or decayingrapidly to a minimum or floor value. For example, following the sense ofR-wave R₃, the secondary auto-adjust threshold is reset to a maximumvalue that is approximately 30% of the magnitude of the sensed R-wave.The secondary auto-adjust threshold 708 remains at this maximum valuefor the duration of a blanking period before decreasing rapidly to aminimum or floor value. As shown, the fast (relative to the firstauto-adjust threshold) decay of the threshold value results in PVC beatPVC₁ being sensed. A determination is made regarding whether theinterval between PVC₁ and R₄ (labeled 712) is greater than thebradycardia threshold. If it is not, then the bradycardia sense withrespect to the primary sense channel is discarded. As shown with respectto the remainder of the EGM signal, PVC beats are successfully detected,thereby preventing erroneous bradycardia senses with respect to thesebeats as well (assuming the resulting intervals are less than thebradycardia interval).

FIG. 8 is a functional schematic diagrams illustrating implementation ofdual sense channels according to another embodiments of the presentinvention. In the embodiment shown in FIG. 8, first sensing channel 800once again includes pre-amplifier 802, band-pass filter 804, rectifier806, and primary auto-adjusting threshold 808. However, in contrast withthe embodiment shown in FIG. 6, secondary sensing channel 810 includes asecond band-pass filter 812, second rectifier 814, and secondaryauto-adjusting threshold 816.

In the embodiment shown in FIG. 8, primary sensing channel 800 operatesin the same way as primary sensing channel 600 described with respect toFIG. 6. Primary sensing channel 800 comprises pre-amplifier 802,band-pass filter 804, rectifier 806, and auto-adjusting threshold 808utilized to detect sense events (e.g., R-waves) based on a monitored EGMsignals. Secondary sensing channel 810, however, utilizes a separateband-pass filter 812 and rectifier 814 used to filter/rectify the rawEGM signal. In the embodiment shown in FIG. 8, the band-pass filter isdesigned to target/accentuate lower frequency components (e.g., 6 Hz to20 Hz) than those targeted by first band-pass filter 804 (e.g., 10 Hz to32 Hz). As described above with respect to FIG. 7B, PVC beats typicallyinclude lower frequency components (i.e., wider QRS complex) thantypical r-waves. In this way, the filtered/rectified EGM signalgenerated by band-pass filter 812 and rectifier 814 will accentuate(convert to higher magnitudes) PVC beats as well as other beats withlower frequency components (wide-complex QRS).

Secondary auto-adjusting threshold 816 is designed to take advantage ofthe filtered/rectified EGM signal generated by band-pass filter 812 andrectifier 814. For example, because band-pass filter 812 is designed toaccentuate lower frequency content such as those associated with PVCs,secondary auto-adjusting threshold 816 may be programmed with a maximumlevel that is greater than that employed by secondary auto-adjustingthreshold 612 (shown in FIG. 6). Similarly, the programmed minimum valueor floor utilized in secondary auto-adjusting threshold 816 may begreater than that utilized by second auto-adjusting threshold 612. Inthis way, secondary sensing channel 810 is utilized to detect eventsunder-sensed by primary sensing channel 800.

In one embodiment, the combination of second band-pass filter 812,second rectifier 814 and secondary auto-adjusting threshold 816 allowsfor the detection of T-waves by secondary sensing channel 810. Ingeneral, T-waves are typically lower in frequency than R-waves, and thusthe lower band of frequencies selected by band-pass filter 812accentuates the T-wave component and makes it easier to sense. A benefitof sensing T-waves (in addition to R-waves), is that the sensed T-wavesmay be utilized to measure the QT interval (time between a detected QRScomplex and a detected t-wave). For example, the location of the T-wavecan be determined as the point when the filtered rectified amplitude isat a maximum value in a later portion of the blanking window of thesecondary sense channel.

FIG. 9 is a flowchart of a method 900 of detecting and validatingbradycardia detections utilizing a first and second channel according toan embodiment of the present invention. The method described withrespect to FIG. 9 may be implemented, for example, by either of the dualchannel sensing systems described with respect to FIGS. 6 and 8.

At step 902, a sense event (e.g., R-wave) is sensed in the primarychannel. As described with respect to FIGS. 6 and 8, afiltered/rectified EGM signal is compared to a threshold value such asan auto-adjusting threshold value to detect R-waves.

At step 904, the interval between sensed R-waves (i.e., R-R interval) iscompared to a bradycardia threshold. If the R-R interval is less thanthe bradycardia threshold, then the patient's heart rate is faster thanthat indicative of a bradycardia and the sensing of R-waves continues atstep 902. If the R-R interval is greater than the bradycardia threshold,then the R-R segment is identified as a bradycardia event. For example,in some embodiments, the second R-wave in the R-R segment is labeled asa bradycardia beat. In other embodiments, the second-wave in the R-Rsegment is not labeled until after the detected bradycardia has beenverified by the second channel. If a bradycardia event is detected atstep 904, then the method continues at step 906.

At step 906, the R-R sense interval that led to the bradycardia senseevent is processed using the secondary channel. It should be noted thatwhile the steps are ordered in ascending numerical order, this does notrequire that the steps be performed in this order. In one embodiment,processing of the R-R interval is always performed by the secondarychannel contemporaneously with processing performed in the primarychannel. However, events sensed in the secondary sensing channel areonly utilized if a bradycardia is detected in the primary sensingchannel. However, in other embodiments the R-R interval may be stored toa buffer or memory in response to a detected bradycardia sense event,and the stored EGM is subsequently processed by the secondary sensingchannel to verify the bradycardia event.

As described with respect to FIGS. 6 and 8, the secondary channel mayinclude a separate, secondary auto-adjust threshold that is utilized todetect additional events within the R-R interval, or may additionallyinclude hardware to filter/rectify the EGM signal before applying asecondary threshold. In particular, as discussed above, the secondarychannel is configured to detect irregular beats that were under-sensedby the primary channel, such as PVC beats as well as wide QRS complexbeats.

At step 908, based on events sensed by the secondary channel, measuredR-R intervals are compared to the bradycardia threshold to determinewhether the bradycardia detected at step 904 should be rejected orconfirmed. If no additional events were sensed by the secondary channelwithin the R-R interval, then the R-R interval will remain unchanged andthe bradycardia event detected at step 904 is confirmed at step 910.However, if additional sense events are sensed by the secondary channel,and the resulting R-R interval is less than the bradycardia intervalthen the bradycardia sense event detected at step 904 is rejected atstep 912 as inappropriate.

FIGS. 10A-10C and 11 illustrate another method utilized to detectbradycardia events that utilizes a secondary threshold to verify abradycardia event detected in the first channel. In particular, themethod described with respect to FIGS. 10A-10C and 11 are well-suitedfor implementation in firmware. For example, with respect to theembodiment shown in FIG. 2, firmware included as part of microprocessor224 may programmed to implement the described method. In otherembodiments, the method may be implemented in hardware, software, or acombination thereof.

In particular, FIG. 10A illustrates a raw (i.e., unfiltered) electrogram(EGM) signal. In the example shown in FIG. 10A, a R-wave R₁ is followedby a PVC beat, and then another R-wave R₂. FIG. 10B illustrates thefiltered/rectified EGM signal (solid black line) as compared with thefirst auto-adjust threshold 1000 (dashed line). Once again,filtering/rectifying of the EGM signal results in the higher frequencyR-waves having higher amplitudes than the lower frequency PVC beats. Asa result, the first auto-adjust threshold 1004 reset in response to thesense of R-wave R₁ under-senses the PVC beat (i.e., the PVC beat doesnot exceed the first auto-adjust threshold 1000, and therefore is notdetected). The resulting R-R interval sensed by the primary sensechannel (denoted interval 1002) is greater than a bradycardia threshold,and therefore results in detection of a bradycardia event (denoted bythe label ‘B S’ underneath R-wave R2.

FIG. 10C illustrates utilization of a secondary sense threshold 1004(dashed line) to confirm or reject the bradycardia detection made by theprimary sensing channel. In contrast with the embodiment shown in FIGS.6 and 8, the embodiment shown in FIG. 10C is most likely to beimplemented by firmware, in which following detection of bradycardiaevent in the first sensing channel, the corresponding EGM segment isstored to a buffer or memory (e.g., RAM 226 shown in FIG. 1) and thensubsequently processed retrospectively as shown in FIG. 10C. In oneembodiment, a four-point moving average filter is applied to the EGMsegment, after taking a single point difference of the raw EGM, thatextends from the previous sense to the current sense (i.e., the R-Rinterval identified as a bradycardia event) to obtain an averaged EGMsegment. In addition, blanking periods are extracted from the EGMsegment to prevent sensing events within the blanking periods. In theembodiment shown in FIG. 10C, T-wave blanking period 1010 extends for aperiod of time from the previous R-wave sense, while P-wave blankingperiod 1012 extends for a period of time preceding the subsequent R-wavesense. The purpose of T-wave blanking period 1010 is to prevent sensingT-waves occurring shortly thereafter a detected R-wave (e.g., R-waveR1). Similarly, the purpose of P-wave blanking period 1012 is to preventthe sensing of P-waves that precede the subsequently detected R-wave(e.g., R-wave R2). Typically, T-wave blanking period 1010 will extendfor a longer duration of time than P-wave blanking period 1012.Secondary sense threshold 1004 is calculated/selected that will be usedto detect additional sense events within the secondary average EGMsegment (i.e., the portion of the EGM segment that extends from the endof T-wave blanking period 1010 to the start of the P-wave blankingperiod 1012). In one embodiment, the magnitude of the secondary sensethreshold 1016 is a function of the amplitude of the previously sensedR-wave (e.g., 30-65% of the magnitude of R-wave R1). In one embodiment,the secondary sense threshold 1004 is a function of the amplitude of thepreviously sensed R-wave unless the amplitude of the sensed R-wave isless than a selected value (e.g., 10000, in which case the secondarysense threshold 1004 is assigned a programmable value (e.g., half of thenominal value or 50 μV).

The EGM segment—minus the blanking periods—is then compared to thesecondary sense threshold 1004 to detect events under-sensed by theprimary sense channel. In the embodiment shown in FIG. 10C, the portionof the filtered/rectified EGM signal representing the PVC beat crossesthe secondary sense threshold 1004 and is therefore detected. As aresult of the detected PVC beat, and resulting R-R interval 1020 beingless than the bradycardia threshold, the bradycardia event detected bythe primary sense channel is rejected.

FIG. 11 is a flowchart of a method 1100 of detecting and validatingbradycardia detections utilizing a secondary threshold according to anembodiment of the present invention. At step 1102, R-wave sensing in theprimary channel allows an R-R interval to be determined. At step 1104,the R-R interval is compared to the bradycardia threshold. If the R-Rinterval sensed by the primary channel is not greater than thebradycardia threshold, then no bradycardia event is detected and normalsensing in the primary channel continues at step 1102. If the R-Rinterval sensed in the primary channel is greater than the bradycardiathreshold, then a bradycardia event is detected and the method continuesto steps 1106-1120 to either verify or reject the bradycardia senseevent.

At step 1106, the EGM associated with the R-R sense interval thatresulted in the bradycardia detection is stored to a buffer or memory.In one embodiment, the stored EGM segment is the raw EGM signal. Inother embodiments, different forms of filtered and/or rectified EGMsegments are stored to the buffer or memory. At step 1108, a movingaverage is applied to the R-R interval to minimize localized distortionsin the stored R-R sense interval. In one embodiment, a four-point movingaverage is applied to the R-R interval, although in other embodimentsother types of moving averages may be employed. At step 1110, blankingperiods including the T-wave blanking period and P-wave blanking periodare removed from the averaged EGM signal. The purpose of extracting theblanking periods from the averaged EGM signal is to prevent the sensingof T-waves and P-waves in subsequent steps. If it is desirable to senseT-waves and/or P-waves, the blanking periods may be modifiedaccordingly.

At step 1112, the secondary threshold is calculated and/or selected. Inone embodiment the secondary threshold is selected as a function of themagnitude of the previously sensed R-wave. However, because thesecondary threshold does not decay once selected, the secondarythreshold is selected to equal a value that will lead to detection ofevents such as PVC beats. In one embodiment, the secondary threshold isa fixed value (e.g., 50 μV). In other embodiments, the secondarythreshold may be selected as a function of the r-wave amplitude (e.g.,12% of “large” r-wave amplitudes and 40% of “smaller” r-waveamplitudes). In addition, if the magnitude of the previously sensedR-wave is below a threshold value (e.g., 100 μV), then rather than setthe secondary threshold to a value that may result in the over-sensingof artifacts/noise events, the secondary threshold is set to a nominalvalue (e.g., 50 μV).

At step 1114, the averaged EGM signal is compared to the secondarythreshold to detect additional events within the R-R interval thatresulted in the bradycardia detection. An event is detected when theaveraged EGM signal exceeds the value of the secondary threshold. Atstep 1116, the secondary R-R intervals detected as a result ofadditionally sensed events within the initial R-R interval is comparedto the bradycardia interval. It is possible that despite the detectionof additional events in the initial R-R interval, the resultingsecondary R-R intervals still exceed the bradycardia interval, and thusthe bradycardia sense event is still confirmed. If the secondary senseinterval is greater than the bradycardia threshold, then the bradycardiasense event is confirmed at step 1118. If the secondary R-R senseinterval is less than the bradycardia interval, the detected bradycardiaevent is rejected at step 1120. In other embodiments, other rules may beutilized to confirm or deny the bradycardia sense event (e.g., any senseevent in the secondary channel will lead to a rejection of a bradycardiasense event irrespective intervals). For example, an additional rule mayrequire that the resulting secondary R-R intervals must also be greaterthan a threshold value (e.g., 200 ms) to prevent P-wave over-sensing. Inthis way, the embodiment shown in FIG. 11 provides a method of detectingand verifying bradycardia events that only requires modifications to theinstalled firmware within a monitoring device or system.

The system and methods described above for reducing inappropriatedetection of bradycardia sense events may be extended to reducinginappropriate pause detection, which refers to an asystole event definedas no ventricular events over a defined period of time (e.g., fourseconds).

Inappropriate Asystole Detection

FIGS. 12A-12C illustrate graphically the use of a secondary thresholdand secondary timer to confirm or reject a pause or asystole eventdetected in the primary sensing channel. In particular, FIG. 12Aillustrates a raw electrogram (EGM) signal having a PVC beat followed bythree consecutive R-waves R1, R2, and R3. FIG. 12B the EGM signalfollowing filtering/rectification, and further shows the under-sensingof the R-waves R1, R2, and R3 by the primary sensing channel, whichleads to an improper pause detection. FIG. 12C illustrates the use of asecondary sensing threshold to detect the under-sensed R-waves R1, R2,and R3 and reject the inappropriate pause detection. One differencebetween the reduction of inappropriate bradycardia sense eventsdescribed with respect to FIGS. 5-11 and the reduction of inappropriatepause/asystole detections shown in FIGS. 12A-12C and 13 is that thebradycardia sense events were detected with respect to R-R intervals,whereas pause detections can be based on a detected escape beat or adetected sense event. The escape beat may be followed by a subsequentsense event (e.g., R-wave) or may include a sense event followed by anescape beat.

For example, with respect to FIG. 12B, the PVC beat is detected and theprimary sense threshold 1204 (in this embodiment, an auto-adjustthreshold) is reset and begins to decay to a minimum or floor value.However, due to the magnitude of the PVC beat, the primary sensethreshold decays to a value that is still greater than the amplitude ofthe successive filtered/rectified R-waves R1, R2, and R3. As a result,each of the successive R-waves R1, R2, and R3 is under-sensed by theprimary sensing channel. Following expiration of an escape beat (e.g.,occurring either 2 seconds or 4 seconds after the previous R-wave sense)without another sensed event, a cardiac pause or asystole is detected.For example, in the embodiment shown in FIG. 12B, the pause interval1205 has not been reset by a detected sense, and therefore has increasedto a magnitude indicating a cardiac pause or asystole.

In response to the detected pause or asystole, a secondary threshold1206 is utilized to detect under-sensed events within the pauseinterval. In the embodiment shown in FIG. 12C, the secondary threshold1206 is a function of the magnitude of the previously sensed event (inthis case the PVC beat), and includes a T-wave blanking period 1208. Theembodiment shown in FIG. 12C utilizes a secondary threshold 1206 thatmay be implemented in firmware, similar to that shown in FIGS. 10A-10Cand 11. However, in other embodiments a secondary sense channel may beutilized to detect the under-sensed events, similar to that shown inFIGS. 5-9. For example, rather than a secondary threshold, a secondsensing channel may be employed that utilizes a secondary auto-adjustthreshold.

In response to the sense event that begins the detected pause interval,a secondary timer 1210 begins to run and continues until the next eventis sensed utilizing the secondary threshold 1206. For example, in theembodiment shown in FIG. 12C, R-wave R1 is sensed, resulting insecondary timer 1210 being reset to zero. If no events are sensed, thensecondary timer 1210 continues to increment until the escape beat isreached, at which time the secondary timer 1210 is compared to the pauseinterval threshold or asystole detection interval. If the secondarytimer 1210 is greater than the pause interval threshold, then the pauseor asystole event detected by the primary channel is verified. If thesecondary timer 1210, on account of being reset as a result of a sensedevent, is less than the pause interval, then the pause interval (orasystole) detected by the primary sense channel is determined to havebeen erroneous and is discarded.

FIG. 13 is a flowchart of a method of detecting and validating pauseintervals utilizing a secondary threshold and secondary timer accordingto an embodiment of the present invention. At step 1302 events aresensed in the primary sense channel using a first threshold. Sensedevents may include r-waves, PVC beats, etc. At step 1304 either anescape beat is detected following a sensed event or an event is sensedfollowing an escape beat. In either case, the detection of an escapebeat triggers a comparison of the interval between the sensed event andthe escape beat (labeled here as the R-E interval) to a pause intervalat step 1306. If at step 1306 the R-E interval is determined to be lessthan the pause interval, then no pause or asystole event is detected andthe process continues at step 1302. However, if at step 1306 the R-Einterval is determined to be greater than the pause interval, then apause or asystole event is detected and the process continues at steps1108-1128 to verify the detected pause or asystole event.

In the embodiment shown in FIG. 13, at step 1308 the EGM segment thatresulted in the pause or asystole detect is stored/buffered to memoryand processed. The embodiment shown in FIG. 13 relies on a firmwareimplementation wherein the EGM segment(s) that resulted in the detectedpause interval is buffered/stored and analyzed using a calculatedsecondary threshold. In other embodiments, the EGM segment may beprovided to a secondary channel that includes a secondary auto-adjustthreshold utilized to detect events in the pause interval. In thislatter embodiment, it may not be necessary to store/buffer the EGmsegment to memory for processing as the processing may be donecontemporaneously with processing of the first channel. Processing theEGM segment includes applying a moving average filter of single sampledifference to the raw EGM segment that represents the pause or asystoleevent to obtain an averaged EGM segment. In one embodiment, thisincludes applying a four-point moving average filter of the singlesample difference to the raw EGM signal that represents the pause orasystole segment (this includes applying the moving average from aprevious sense (e.g., VSENSE_(n-1)) or escape beat (e.g., ESCAPE_(n-1))to a current escape beat (e.g., ESCAPE_(n)) or current sense (e.g.,VSENSE_(n)). In addition, processing of the EGM segment may includeextracting portions of the averaged/filtered EGM segment to account forblanking periods utilized to avoid over-sensing P-waves and T-waves. Forexample, if the ECG segment is measured from a previous sense(VSENSE_(n-1)) to a current escape beat (ESCAPE_(n)), then the averageEGM segment extracted accounts for a blanking period (twaveBlank) thatimmediately follows the previous sense (VSENSE_(n-1)). This isillustrated graphically in FIG. 12C, which illustrates a t-wave blankingperiod 1208 extending from the previous sensed event (in this case, aPVC beat). In this way, the portion of the EGM segment analyzed extendsfrom the previously sensed event (VSENSE_(n-1)+twaveBlank) to thecurrent escape beat (ESCAPE_(n)). If the EGM segment extends from aprevious escape beat (ESCAPE_(n-1)) to a current escape beat(ESCAPE_(n)), then no blanking periods are utilized and the extractedfiltered/averaged EGM segment extends from the previous escape beat(ESCAPE_(n-1)) to the current escape beat (ESCAPE_(n)). Finally, if theEGM segment extends from a previous escape beat (ESCAPE_(n-1)) to acurrent sense (VSENSE_(n)), then the extracted filtered/averaged EGMsegment extends from the previous escape beat (ESCAPE_(n-1)) to thecurrent sense event minus a p-wave blanking period(VSENSE_(n)−pwaveBlank).

At step 1310 a second threshold is calculated that is more sensitivethan the first threshold to allow for the detection of eventsunder-sensed by the first threshold. In one embodiment, the magnitude ofthe second threshold is a function of the magnitude of the previouslysensed event (e.g., 30% of the magnitude of the previously sensedevent). In addition, if the previously sensed event is less than anominal value (e.g., 100 μV), then the second threshold may be set equalto a predetermined value (e.g., half of the nominal value or 50 μV).

At step 1312 the secondary timer is started. In one embodiment, thesecondary timer is assigned a timer value of twaveBlank in response to aprevious sense event (VSENSE_(n-1)).

At step 1314, with the secondary timer running, the filtered/averagedEGM segment is compared with the secondary threshold. An event isdetected in response to any point in the filtered/averaged EGM signalexceeding the value of the secondary threshold. If a VSENSE event isdetected at step 1314, then at step 1316 the secondary timer is reset tozero, and the method continues at step 1318 to determine whether the EGMsegment has been processed. Resetting the secondary timer to zeroindicates that an event has been sensed that was not previously sensed,and therefore that the pause or asystole event will need to bereevaluated from the location of the previously under-sensed event. Anexample of this is shown in FIG. 12C, in which detection of R-wave R₁ bythe secondary threshold results in secondary timer being reset to zero,before beginning to increase or increment. If no event is detected atstep 1314, then the secondary timer continues to increment/increase anda determination is made at step 1318 of whether processing of the EGMsegment is complete.

If at step 1318 it is determined that the EGM segment has not beenprocessed, then the method continues at step 1314 in processing the EGMsegment for previously under-sensed events. If at step 1318 it isdetermined that the EGM segment has been processed, then at step 1320the secondary timer is incremented (if not incrementing continuously)and the method continues at step 1322 to determine whether additionalEGM segments need to be processed. If it is determined that additionalEGM segments do need to be processed then the method continues at step1314. If it is determined that all EGM segments in the pause intervalhave been processed, then at step 1324 the duration of the secondarytimer is compared to the pause/asystole threshold. If the secondarytimer is greater than the pause/asystole threshold—indicating that thesecondary timer was not reset or at least was not reset very often as aresult of detecting previously under-sensed events—then the pause orasystole even detected via the primary channel is confirmed at step1326. If, on the other hand, the secondary timer is NOT greater than thepause/asystole threshold then the pause/asystole event detected in theprimary channel is rejected.

In this way, the present disclosure provides a system and method ofdetecting and verifying events characterized by long intervals betweensensed events, such as bradycardia events, cardiac pause events, andasystole events. In particular, the system and methods make use of aprimary channel for detecting the condition, and then a secondarythreshold/channel for verifying the detected condition. The purpose ofthe secondary threshold/channel is to detect events that wereunder-sensed in the primary channel. For example, the secondarythreshold/channel may be designed to detect premature ventricularcontractions (PVCs) that follow a normal QRS complex (r-wave).

Discussion of Possible Embodiments

The following are non-exclusive descriptions of possible embodiments ofthe present invention.

A method of verifying detected bradycardia and/or asystole. The methodmay include sensing an electrogram (EGM) signal. In addition, the methodmay include comparing an amplitude of the EGM signal to a primarythreshold to sense events in the EGM signal and detecting at least oneof a bradycardia or an asystole based on the sensed events. In responseto detecting at least one of a bradycardia or an asystole, the EGMsignal may be compared to a secondary threshold to sense eventsunder-sensed by the primary threshold. Based on the detection ofunder-sensed events, the method may determine whether the bradycardia orthe asystole detected is false.

The method of the preceding paragraph can optionally include,additionally and/or alternatively any, one or more of the followingfeatures, configurations and/or additional components.

The method may further include wherein the primary threshold is anauto-adjusted threshold and the secondary threshold is an auto-adjustedthreshold. In addition, the method may further include wherein thesecondary auto-adjusting threshold decays to a minimum value morequickly than the primary auto-adjusting threshold. In addition, themethod may further include wherein the secondary auto-adjustingthreshold is initialized to a maximum value following a sense event,wherein the maximum value is a function of an amplitude of the sensedevent, and wherein the maximum value associated with the secondaryauto-adjusting threshold is less than a maximum value associated withthe primary auto-adjusting threshold.

The method may further include filtering and rectifying the sensed EGMsignal in a primary sense channel and applying the primary auto-adjustthreshold to the filtered/rectified EGM signal. In addition, the methodmay include applying the secondary auto-adjust threshold to thefiltered/rectified EGM signal.

The method may further include filtering and rectifying the sensed EGMsignal in the secondary sense channel to generate a secondaryfiltered/rectified EGM signal. The secondary auto-adjust threshold maythen be applied to the secondary filtered/rectified EGM signal, whereinfiltering in the secondary sense channel may select lower frequencycomponents than filtering in the primary sense channel.

The method may further include starting a secondary timer in response toa detected asystole. In addition, the secondary timer may be reset inresponse to detection of an under-sensed event via application of thesecondary threshold. The detected asystole may be determined to be falsebased on the value of the secondary timer.

The method may further include starting the secondary timer in responseto at least one of a sensed event or escape beat that marks a beginningof the detected asystole.

In another embodiment, a medical device may include a sensing unit, aprimary sensing channel, a secondary sensing channel, and a processor.The sensing unit may monitor an EGM signal, and the primary sensingchannel may apply a primary threshold to the EGM signal to detect senseevents within the EGM signal. In addition, a secondary sensing channelmay apply a secondary threshold to the EGM signal to detect under-sensedevents within the EGM signal. The a processor may detect at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel, wherein the processor determines whether the detectedbradycardia or asystole is false based on detection of under-sensedevents by the secondary sensing threshold.

The medical device of the preceding paragraph can optionally include,additionally and/or alternatively any, one or more of the followingfeatures, configurations and/or additional components.

For example, the primary threshold utilized by the medical device may bea primary auto-adjusting threshold and the secondary threshold may be asecondary auto-adjusting threshold, wherein the secondary auto-adjustingthreshold may decay to a minimum value more quickly than the primaryauto-adjusting threshold.

The secondary auto-adjusting threshold of the medical device may beinitialized to a maximum value following a sense event, wherein themaximum value may be a function of an amplitude of the sensed event, andwherein the maximum value associated with the secondary auto-adjustingthreshold may be less than a maximum value associated with the primaryauto-adjusting threshold.

The primary sensing channel of the medical device may further include aprimary band-pass filter applied to the monitored EGM signal to generatea filtered EGM signal utilized by the primary threshold.

The secondary sensing channel of the medical device may further includea secondary band-pass filter applied to the monitored EGM signal togenerate a secondary filtered EGM signal utilized by the secondarythreshold to detect under-sensed events.

In another embodiment, a medical device may include a sensing unit, aprimary sensing channel, a processor and a memory unit. The sensing unitmay monitor an electrogram (EGM) signal. The primary sensing channel mayapply a primary threshold to the EGM signal to detect sense eventswithin the EGM signal. The processor may detect at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel. The memory unit may store the EGM segments associatedwith a detected bradycardia or asystole, wherein the processor maydetermine whether the detected bradycardia or asystole is false byapplying a secondary threshold to the stored EGM segments to detectunder-sensed events in the EGM segments.

The medical device of the preceding paragraph can optionally include,additionally and/or alternatively any, one or more of the followingfeatures, configurations and/or additional components.

The processor of the medical device may calculate an amplitude of thesecondary threshold based on an amplitude of a sensed event in thestored EGM segment.

The processor of the medical device may remove blanking periods from thestored EGM segment to prevent the secondary threshold from sensingT-waves and P-waves.

In another embodiment, the medical device may further include means forsensing an electrogram (EGM) signal. The medical device may includemeans for comparing an amplitude of the EGM signal to a primarythreshold to sense events in the EGM signal and may include means fordetecting at least one of a bradycardia or an asystole based on thesensed events. The medical device may also include a means for comparingthe EGM signal to a secondary threshold to sense events under-sensed bythe primary threshold in response to detecting at least one of abradycardia or an asystole. The medical device may further include meansfor determining whether the detection of the bradycardia or the asystoleis false based on the detection of under-sensed events.

The medical device of the preceding paragraph can optionally include,additionally and/or alternatively any, one or more of the followingfeatures, configurations and/or additional components.

The medical device may detect a bradycardia if an interval between senseevents in the EGM signal is greater than a bradycardia threshold,wherein the bradycardia event may be verified if the secondary thresholddoes not detect under-sensed events in the interval between senseevents.

The medical device may further include a secondary timer that isinitialized and started in response to a detected asystole, wherein thesecondary timer may be reset in response to detection of an under-sensedevent by the secondary threshold, and wherein the detected asystole isdetermined to be false based on the value of the secondary timerfollowing the asystole.

In another embodiment, an insertable cardiac monitor includes a firstelectrode located at a distal end of the insertable cardiac monitor anda second electrode located at a proximal end of the insertable cardiacmonitor. The insertable cardiac monitor may further include a sensingunit coupled to the first and second electrode to monitor an electrogram(EGM) signal and a primary sensing channel that applies a primarythreshold to the EGM signal to detect sense events within the EGMsignal. A processor may be utilized to detect at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel. In addition, the insertable cardiac monitor may includea secondary sensing channel that applies a secondary threshold to theEGM signal to detect under-sensed events within the EGM signal. Theprocessor may further be utilized to determine whether the detectedbradycardia or asystole is false based on detection of under-sensedevents by the secondary sensing threshold.

The medical device of the preceding paragraph can optionally include,additionally and/or alternatively any, one or more of the followingfeatures, configurations and/or additional components.

The insertable cardiac monitor may further include a housing having alength, a width and a depth, wherein the length is much greater than thewidth and the width is greater than the depth.

The primary threshold utilized by the primary sensing channel may be aprimary auto-adjusting threshold. In addition, the secondary thresholdutilized by the secondary sensing channel may be a secondaryauto-adjusting threshold, wherein the secondary auto-adjusting thresholddecays to a minimum value more quickly than the primary auto-adjustingthreshold.

While the invention has been described with reference to an exemplaryembodiment(s), it will be understood by those skilled in the art thatvarious changes may be made and equivalents may be substituted forelements thereof without departing from the scope of the invention. Inaddition, many modifications may be made to adapt a particular situationor material to the teachings of the invention without departing from theessential scope thereof. Therefore, it is intended that the inventionnot be limited to the particular embodiment(s) disclosed, but that theinvention will include all embodiments falling within the scope of theappended claims.

1. A method comprising: sensing an electrogram (EGM) signal; comparingan amplitude of the EGM signal to a primary threshold to sense events inthe EGM signal; detecting at least one of a bradycardia or an asystolebased on the sensed events; in response to detecting at least one of abradycardia or an asystole, comparing the EGM signal to a secondarythreshold to sense events under-sensed by the primary threshold; anddetermining whether the detection of the bradycardia or the asystole isfalse based on the detection of under-sensed events.
 2. The method ofclaim 1, wherein the primary threshold is an auto-adjusted threshold andthe secondary threshold is an auto-adjusted threshold.
 3. The method ofclaim 2, wherein the secondary auto-adjusting threshold decays to aminimum value more quickly than the primary auto-adjusting threshold. 4.The method of claim 2, wherein the secondary auto-adjusting threshold isinitialized to a maximum value following a sense event, wherein themaximum value is a function of an amplitude of the sensed event, andwherein the maximum value associated with the secondary auto-adjustingthreshold is less than a maximum value associated with the primaryauto-adjusting threshold.
 5. The method of claim 2, further including:filtering and rectifying the sensed EGM signal in a primary sensechannel and applying the primary auto-adjust threshold to thefiltered/rectified EGM signal; and applying the secondary auto-adjustthreshold to the filtered/rectified EGM signal.
 6. The method of claim2, further including: filtering and rectifying the sensed EGM signal ina primary sense channel to generate a primary filtered/rectified EGMsignal, wherein the primary auto-adjust threshold is applied to theprimary filtered/rectified EGM signal; and filtering and rectifying thesensed EGM signal in a secondary sense channel to generate a secondaryfiltered/rectified EGM signal, wherein the secondary auto-adjustthreshold is applied to the secondary filtered/rectified EGM signal,wherein filtering in the secondary sense channel selects lower frequencycomponents than filtering in the primary sense channel.
 7. The method ofclaim 1, further including: starting a secondary timer in response to adetected asystole; resetting the secondary timer in response todetection of an under-sensed event via application of the secondarythreshold; and determining whether the detected asystole is false basedon the value of the secondary timer following the asystole.
 8. Themethod of claim 7, wherein the secondary timer is started in response toat least one of a sensed event or escape beat that marks a beginning ofthe detected asystole.
 9. A medical device comprising: a sensing unitthat monitors an electrogram (EGM) signal; a primary sensing channelthat applies a primary threshold to the EGM signal to detect senseevents within the EGM signal; a secondary sensing channel that applies asecondary threshold to the EGM signal to detect under-sensed eventswithin the EGM signal; and a processor that detects at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel, wherein the processor determines whether the detectedbradycardia or asystole is false based on detection of under-sensedevents by the secondary sensing threshold.
 10. The medical device ofclaim 9, wherein the primary threshold is a primary auto-adjustingthreshold and the secondary threshold is a secondary auto-adjustingthreshold, wherein the secondary auto-adjusting threshold decays to aminimum value more quickly than the primary auto-adjusting threshold.11. The medical device of claim 10, wherein the secondary auto-adjustingthreshold is initialized to a maximum value following a sense event,wherein the maximum value is a function of an amplitude of the sensedevent, and wherein the maximum value associated with the secondaryauto-adjusting threshold is less than a maximum value associated withthe primary auto-adjusting threshold.
 12. The medical device of claim 9,wherein the primary sensing channel includes a primary band-pass filterapplied to the monitored EGM signal to generate a filtered EGM signalutilized by the primary threshold.
 13. The medical device of claim 12,wherein the secondary sensing channel includes a secondary band-passfilter applied to the monitored EGM signal to generate a secondaryfiltered EGM signal utilized by the secondary threshold to detectunder-sensed events.
 14. A medical device comprising: a sensing unitthat monitors an electrogram (EGM) signal; a primary sensing channelthat applies a primary threshold to the EGM signal to detect senseevents within the EGM signal; a processor that detects at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel; and a memory unit that stores EGM segments associatedwith a detected bradycardia or asystole, wherein the processordetermines whether the detected bradycardia or asystole is false byapplying a secondary threshold to the stored EGM segments to detectunder-sensed events in the EGM segments.
 15. The medical device of claim14, wherein the processor calculates an amplitude of the secondarythreshold based on an amplitude of a sensed event in the stored EGMsegment.
 16. The medical device of claim 15, wherein the processorremoves blanking periods from the stored EGM segment to prevent thesecondary threshold from sensing T-waves and P-waves.
 17. A medicaldevice comprising: means for sensing an electrogram (EGM) signal; meansfor comparing an amplitude of the EGM signal to a primary threshold tosense events in the EGM signal; means for detecting at least one of abradycardia or an asystole based on the sensed events; in response todetecting at least one of a bradycardia or an asystole, means forcomparing the EGM signal to a secondary threshold to sense eventsunder-sensed by the primary threshold; and means for determining whetherthe detection of the bradycardia or the asystole is false based on thedetection of under-sensed events.
 18. The medical device of claim 17,wherein bradycardia is detected if an interval between sense events inthe EGM signal is greater than a bradycardia threshold, wherein thebradycardia event is verified if the secondary threshold does not detectunder-sensed events in the interval between sense events.
 19. Themedical device of claim 17, further including: a secondary timer that isinitialized and started in response to a detected asystole; wherein thesecondary timer is reset in response to detection of an under-sensedevent by the secondary threshold, and wherein the detected asystole isdetermined to be false based on the value of the secondary timerfollowing the asystole.
 20. An insertable cardiac monitor comprising: afirst electrode located at a distal end of the insertable cardiacmonitor; a second electrode located at a proximal end of the insertablecardiac monitor; sensing unit coupled to the first and second electrodeto monitor an electrogram (EGM) signal; a primary sensing channel thatapplies a primary threshold to the EGM signal to detect sense eventswithin the EGM signal; a secondary sensing channel that applies asecondary threshold to the EGM signal to detect under-sensed eventswithin the EGM signal; and a processor that detects at least one ofbradycardia or asystole based on sense events detected by the primarysensing channel, wherein the processor determines whether the detectedbradycardia or asystole is false based on detection of under-sensedevents by the secondary sensing threshold.
 21. The insertable cardiacmonitor of claim 20, further comprising a housing having a length, awidth and a depth, wherein the length is much greater than the width andthe width is greater than the depth.
 22. The insertable cardiac monitorof claim 20, wherein the primary threshold is a primary auto-adjustingthreshold and the secondary threshold is a secondary auto-adjustingthreshold, wherein the secondary auto-adjusting threshold decays to aminimum value more quickly than the primary auto-adjusting threshold.